Dr Lisa Jayne Adams November 2007 CONTRACEPTION for GPs Dr Lisa Jayne Adams November 2007

AGENDA Non-hormonal contraception Hormonal contraception Cases

Contraceptive Efficacy Pearl Index Effectiveness rates depend on age and motivation of user Most effective? A method that stops ovulation and is independent of user compliance

Withdrawal Mentioned in the Bible No side effects Pearl index of 8

Natural Family Planning/Persona Complex to explain Calender method Temperature method Cervical mucus Combine all three Pearl Index 8-10 FPA can provide local teachers

PERSONA Pearl Index 6 BREAST FEEDING Pearl Index 2

CONDOMS Most commonly used non-hormonal Pearl Index 3-20 Beware certain topical products Protection against STI’s

FEMALE BARRIER METHODS Femidom Diaphragm Cervical cap

IUDs Banded copper device =gold standard More effective in older women Main problems Duration of use 10 years Can be used for emergency contraception Pearl index 1-3

IUS Periods shorter and lighter Licensed for 5 years Can cause spotting and irregular bleeding for up to 6 months Pearl Index < 1 (included in non-hormonal methods as effects are local)

HORMONAL CONTRACEPTION COCP Pearl index 1-5 Mode of action Non contraceptive benefits Starting regime Late pills/missed pills Diarrhoea/vomiting/ antibiotics

EVRA transdermal combined hormonal contraception Yasmin contains drospirenone, has diuretic and antiandrogen properties NuvaRing

Potential Harms All COCP’s increase the risk of VTE, MI, ischaemic stroke, absolute risk is small Any associated increased risk of breast cancer likely to be small

Non contraceptive Benefits Decreased pain and blood loss Risk of ovarian and endometrial cancer decreased by at least 50% during use Decreased risk of colorectal cancer Decreased incidence functional ovarian cysts

Not Recommended (UKMEC category 4) Smokers >35 years (>15 a day) Migraine with aura at any age Known thrombogenic mutations BMI >40 BP consistently > 160/100 Current breast cancer Liver tumours Hx VTE/Stroke/MI Valvular and congenital heart disease

PRESCRIBING Record BMI and BP Take a full history, check smoking status Use a monophasic pill first line eg microgynon Counsel re risks and side effects Discuss non-contraceptive benefits

POP Thickens cervical mucus Pearl index 0.3- 4 Late pills Cerazette (desogestrel) more effective, blocks ovulation in 97% of cycles Advantages Side effects Starting regime

DEPOT PROVERA Deep IM every 12 weeks Pearl index 0.3- 1 Preinjection counselling Unwanted effects Can lower bone density in long-term users

IMPLANON Contraceptive implant etonogestrel Pearl index 0.8 Lasts for 3 years Fitting and counselling Pros and cons

EMERGENCY CONTRACEPTION Levonelle Copper IUD insertion

LEVONELLE Licenced for u to 72 hours after UPSI Prevents 86% of pregnancies Levonogestrel 1500ug Contraindications and drug interactions

EMERGENCY IUD 99.8% effective for postcoital use Copper IUD most effective Contraindications Insert up to 5 days after UPSI If regular cycle can insert up to 5 days after expected date of ovulation

CASE HISTORIES

CASE ONE Carly is 18 years old. She has just had a TOP due to ‘pill failure’. She is off to university soon. She is not in a regular relationship. She admits that she sometimes forgot to take her pill. She really wants to avoid another pregnancy. She wants your advice.

CASE TWO Linda is forty years old, married with three children. She is a non smoker and has been taking the COCP for 7 years. She stopped taking it last week because her younger sister has been admitted to hospital with a DVT. She does not really want any more children. What are her options?

CASE THREE Eve is 25 years old. She is in a stable relationship. She has been using condoms but wants something ‘safer’. She smokes 10 cigarettes a day.

CASE FOUR Sam is 35, she has recently got divorced. She has one child. She has had a coil for the last 9 years. She knows her coil will need changing soon. She is not sure if she wants another one. What is your advice?

CASE FIVE Pippa has come in for her 6 week postnatal check. She is 29 years old. She has a six week old baby and a fifteen month toddler. She is mainly breastfeeding, but gives some formula at night. She feels exhausted. Although her and her partner may want some more children they would like a ‘decent’ gap next time. She wants your advice.

Useful websites Fpa.org.uk (formerly Family Planning Association) BNF online Prescriber.com Attract Prodigy (good for guidelines)

REFERENCES Faculty of Family Planning and Reproductive Health Care Clinical Guidance: First prescription of combined oral contraception (July 2006) Guillebaud, J. Contraception Today. 5th ed. Martin Dunitz, 2005